Post-ligation cardiac syndrome after surgical versus transcatheter closure of patent ductus arteriosus in low body weight premature infants: a multicenter retrospective cohort study

Transcatheter patent ductus arteriosus (PDA) closure is a safe and effective alternative to surgical ligation in low-body-weight infants. Post-ligation cardiac syndrome (PLCS) is defined as severe hemodynamic and respiratory collapse within 24 h of PDA closure, requiring initiation or an increase of an inotropic agent by > 20% of preligation dosing and an absolute increase of at least 20% in ventilation parameters compared with the preoperative value. Whilst PLCS is routinely observed after surgery, its incidence remains poorly described following transcatheter closure. This study aimed to compare the incidence of PLCS after surgical versus transcatheter closure of PDA in low-body-weight premature infants. Propensity scores were used to compare surgical (N = 78) and transcatheter (N = 76) groups of preterm infants who underwent PDA closure at a procedural weight less than 2000 g in two tertiary institutions between 2009 and 2021. The primary outcome was the incidence of PLCS. Secondary outcomes included overall mortality before discharge, risk factors for PLCS, and post-procedural complications. Procedural success was 100% in both groups. After matching, transcatheter group experienced no PLCS vs 15% in the surgical group (p = 0.012). Furthermore, overall mortality (2% vs 17%; p = 0.03) and major complications (2% vs 23%; p = 0.002) were higher in the surgical group. Surgery (100% vs 47%; p < 0.01), gestation age (25 ± 1 vs 26 ± 2 weeks, p < 0.05) and inotropic support before closure (90% vs 29%; p < 0.001) were associated with PLCS occurrence.          Conclusion: Transcatheter PDA closure may be equally effective but safer than surgical PDA closure in low-body-weight premature infants. What is Known: • Post-ligation cardiac syndrome is a serious and common complication of surgical closure of the ductus arteriosus in preterm infants. • Transcatheter closure of preterm ductus arteriosus is a safe and effective technique that is becoming more and more common worldwide. What is New: • Device closure is safer than surgical ligation for patent ductus arteriosus closure in preterm infants and may be the first-line non-pharmacological therapeutic option in this indication in experienced teams. • Our findings should encourage neonatologists and pediatric cardiologists to start and/or strengthen a durable interventional program for transcatheter PDA closure in premature infants.

Risk Factors of Long-Term Sequelae After Transcatheter Closure of Perimembranous Ventricular Septal Defect in Young Children

BACKGROUND

Complications arising from transcatheter closure of perimembranous ventricular septal defects (pmVSD) in children, such as residual shunts and aortic regurgitation (AR), have been observed. However, the associated risk factors remain unclear. This study identified risk factors linked with residual shunts and AR following transcatheter closure of pmVSD in children aged 2-12 years.Methods and Results: The medical records of 63 children with pmVSD and a pulmonary-to-systemic blood flow ratio <2.0 who underwent transcatheter closure between 2011 and 2018 were analyzed with a minimum 3-year follow-up. The success rate of transcatheter closure was 98.4%, with no emergency surgery, permanent high-degree atrioventricular block, or mortality. Defects ≥4.5 mm had significantly higher odds of persistent residual shunt (odds ratio [OR] 6.85; P=0.03). The use of an oversize device (≥1.5 mm) showed a trend towards reducing residual shunts (OR 0.23; P=0.06). Age <4 years (OR 27.38; 95% confidence interval [CI] 2.33-321.68) and perimembranous outlet-type VSD (OR 11.94, 95% CI 1.10-129.81) were independent risk factors for AR progression after closure.

CONCLUSIONS

Careful attention is crucial for pmVSDs ≥4.5 mm to prevent persistent residual shunts in transcatheter closure. Assessing AR risk, particularly in children aged <4 years, is essential while considering the benefits of pmVSD closure.

Relationship between patent foramen ovale anatomical features and residual shunt after patent foramen ovale closure

Transcatheter closure of patent foramen ovale (PFO) is an effective strategy for preventing recurrence of paradoxical embolism. However, PFO closure is often associated with residual shunt, which is a risk of recurrent stroke. This study aimed to evaluate the relationship between the anatomical features of PFO and residual shunt. The degree of residual shunt and its relationship with the anatomical features of PFO were evaluated in 106 patients who underwent PFO closure at our institution between March 2011 and January 2022 and in whom contrast transthoracic echocardiography was performed 1 year later. The mean PFO tunnel length was 9.3 ± 3.6 mm and the mean PFO height was 3.2 ± 2.2 mm. Atrial septal aneurysm (ASA) was found in 37 patients. After PFO closure, residual shunt was observed in 28 patients (grade 1, n = 8; grade 2, n = 16; grade 3, n = 3; grade 4, n = 1). Univariate logistic analysis identified ASA to be associated with residual shunt (odds ratio 2.78, 95% confidence interval 1.14 to 6.79; p = 0.024). There was no association of residual shunt with the size of the PFO, the length of PFO tunnel, or the size of the device used for closure. Two of four patients with a large residual shunt of grade 3 or grade 4 were found to have device size mismatch. Residual shunt after PFO closure was observed in a quarter of patients and was related to the presence of ASA. A few patients had a large residual shunt due to the device size mismatch.

Diagnosis and Management of Congenital Coronary Artery Fistulas in Adults

PURPOSE OF REVIEW

This review describes the presentation, diagnosis, and management of congenital coronary artery fistulas (CAFs) in adults.

RECENT FINDINGS

CAFs are classified as coronary-cameral or coronary arteriovenous fistulas. Fistulous connections at the distal coronary bed are more likely to be aneurysmal with higher risk of thrombosis and myocardial infarction (MI). Medium-to-large or symptomatic CAFs can manifest as ischemia, heart failure, and arrhythmias. CAF closure is recommended when there are attributable symptoms or evidence of adverse coronary remodeling. Closure is usually achievable using transcatheter techniques, though large fistulas may require surgical ligation with bypass. Given their anatomic complexity, cardiac CT with multiplanar 3-D reconstruction can enhance procedural planning of CAF closure. Antiplatelet and anticoagulation are essential therapies in CAF management. CAFs are rare cardiac anomalies with variable presentations and complex anatomy. CAF management strategies include indefinite medical therapy, percutaneous or surgical CAF closure, and lifelong patient surveillance.

Percutaneous Closure of Hemodynamically Significant Postoperative Residual Ventricular Septal Defects

The experience with percutaneous closure of postoperative residual ventricular septal defects (VSDs) is expanding with improved device technology and techniques. To report our experience with percutaneous closure of residual VSDs after cardiac surgeries. Retrospective clinical data review of patients who had percutaneous closure of postoperative residual VSDs at our institution between 2010 and 2022. Patients' demographics, procedural, and follow-up data were looked at. Twelve patients (50% males) with a median age of 9.2 years (range 0.9-22) were identified. Baseline surgeries were 8 tetralogy of Fallot corrections, 2 pulmonary bandings for large muscular VSD (mVSD) including 1 coarctation repair, 1 atrioventricular septal defect repair, 1 sub-aortic membrane resection-induced iatrogenic VSD, 1 isolated VSD closure, and 1 additional mVSD. Median duration between baseline surgery and percutaneous VSD closure was 2.2 years (range 0.2-8.3). Residual VSD shunting was secondary to surgical patch leakage in 8/12 patients. The median angiographic defect diameter was 6.8 mm (range 4.8-14). The defect was balloon-calibrated in 3/12 patients. Defects were tackled retrogradely in 3/9 patients. Amplatzer Membranous VSD occluder (n = 1), Lifetech Multifunctional (n = 5), Membranous (n = 1) and muscular VSD occluders (n = 2) and Occlutech Membranous (n = 1) and Muscular (n = 2) VSD occluders were used. The procedure was successful in 10/12 patients. Two devices embolized to the pulmonary artery and were snare-retrieved. Both patients were referred for surgery. The median follow-up was 1.3 years (range 0.1-12). Six-month ultrasound showed one trivial residual shunt and one mild right ventricular outflow obstruction. One patient is receiving targeted therapy for pulmonary hypertension at 2 years of follow-up. Transcatheter closure of postoperative residual VSDs is a feasible yet challenging intervention. Procedural complications can be encountered.

Transcatheter closure in preterm infants with patent ductus arteriosus: feasibility, results, hemodynamic monitoring and future prospectives

Ductal patency of preterm infants is potentially associated with long term morbidities related to either pulmonary overflow or systemic steal. When an interventional closure is needed, it can be achieved with either surgical ligation or a catheter-based approach.Transcatheter PDA closure is among the safest of interventional cardiac procedures and it is the first choice for ductal closure in adults, children, and infants weighing more than 6 kg. In preterm and very low birth weight infants, it is increasingly becoming a valid and safe alternative to ligation, especially for the high success rate and the minor invasiveness and side effects. Nevertheless, being it performed at increasingly lower weights and gestational ages, hemodynamic complications are possible events to be foreseen.Procedural steps, timing, results, possible complications and available monitoring systems, as well as future outlooks are here discussed.

Outcomes following transcatheter closure or surgical repair of coronary-left ventricular fistula: A single-center study with 10-year experience

BACKGROUND

Coronary arteries drain into the left ventricle, known as coronary-left ventricular fistula (CLVF), an extremely rare anomalous coronary artery disease. Little is known about the outcomes following transcatheter closure (TC) or surgical closure (SC) of CLVF.

METHOD

This was a single-center retrospective study including 42 consecutive patients who underwent either the TC or SC procedure from January 2011 to December 2021. The baseline and anatomic characteristics of the fistulas, procedural outcomes, and late outcomes were summarized and analyzed.

RESULTS

The mean age was 31.6 ± 16.2 years, with 28 male patients (66.7%). Fifteen patients underwent SC group and the remaining received TC group. There were no differences in age, comorbidities, clinical presentations, and anatomic characteristics between the 2 groups. The procedural success rate was similar (93.3% vs. 85.2%, P = 0.639) without operative and in-hospital mortality in both groups. Notably, patients who underwent TC had a significantly shorter postoperative in-hospital length of stay (2.11 ± 1.49 vs. 7.73 ± 2.37 days, P<0.001). The median follow-up time was 4.6 years (2.5-5.7 years, TC group) and 3.98 years (0.42-7.15 years, SC group), respectively. No difference was observed in the incidence of recanalization of the fistula (7.4% vs. 6.7%, P = 1) and myocardial infarction (0% vs. 0%). Cerebral infarction due to discontinuation of anticoagulants happened to two patients in the TC group. Importantly, thrombotic occlusion of the fistulous tract with patent parent coronary artery was found in 7 patients of the TC group.

CONCLUSION

Both transcatheter and SC are safe and effective for patients with CLVF. Thrombotic occlusion is a noteworthy late complication, and its presence indicates the use of anticoagulants lifelong.

Transcatheter closure of postsurgical aortic pseudoaneurysms guided by three-dimensional image reconstruction: a single-centre experience

BACKGROUND

Postsurgical thoracic aortic pseudoaneurysms (PTAPs) are a potentially lethal complication after cardiac or aortic surgery. Surgical management can pose a challenge with high in-hospital mortality rates. Transcatheter closure is a less-invasive alternative treatment option for selected patients, although current experience is limited.

AIMS

We aimed to evaluate procedural and imaging outcomes of our first 11 cases of transcatheter PTAP closure with the use of closure devices.

METHODS

Patients with a high operative risk who underwent transcatheter PTAP closure at our centre from 2019 to 2021 were retrospectively included. Suitability was evaluated on preprocedural computed tomography (CT) scans and three-dimensional (3D) reconstructions. All procedures were performed in the catheterisation laboratory. Intraprocedural aortography and postprocedural CT scans with 3D reconstructions were used to evaluate PTAP occlusion.

RESULTS

Eleven consecutive patients with a high operative risk and a history of cardiac/aortic surgery who underwent transcatheter PTAP closure were included. PTAPs were predominantly located at the proximal or distal anastomosis of a supracoronary ascending aortic vascular graft or Bentall prosthesis (82%). Implanted closure devices included Amplatzer Valvular Plug III (82%), Amplatzer septal occluder (9%) and Occlutech atrial septal defect occluder (9%). No periprocedural complications occurred. After device deployment, residual flow was absent on aortography in 64% and minimal residual flow was present in 36% of patients. Subtotal or total occlusion of the PTAP on follow-up CT ranged between 45% and 73%.

CONCLUSIONS

Although subtotal or total occlusion of the PTAP was found at follow-up in only 45-73% of cases, transcatheter PTAP closure guided by preprocedural 3D reconstructions can offer a valuable minimally invasive primary treatment option for patients who otherwise would face a high-risk reoperation.

Left Atrial Appendage Tilt-Up-and-Turn-Left Maneuver: A Novel Three-Dimensional Transesophageal Echocardiography Imaging Maneuver to Characterize the Left Atrial Appendage and to Improve Transcatheter Closure Guidance

•Precise LAA anatomy must be established for LAA occlusion device selection. •We have developed the TUPLE maneuver, an acronym for “tilt up and turn left”. •The TUPLE maneuver facilitates LAA device selection and intraprocedural guidance.

The value of right heart contrast echocardiography combined with migraine rating scale in evaluating the efficacy of patent foramen ovale closure

OBJECTIVES

To investigate the clinical values of right heart contrast transthoracic echocardiography (cTTE) combined with migraine rating scale in evaluating the efficacy of patent foramen ovale (PFO) closure.

METHODS

From January 2018 to December 2021, a total of 68 hospitalized patients, 21 males and 47 females, who were treated with transcatheter closure of PFO-induced migraine in the Heart Center of the First Affiliated Hospital of Tsinghua University were selected, with the age of 38.4 ± 11.9 years old. The changes of right heart contrast transthoracic echocardiography (cTTE), visual analogue pain score(VAS), headache impact test-6(HIT-6) and migraine disability assessment questionnaire(MIDAS) before and 6 months after PFO occlusion were compared.

RESULTS

Pre-operative cTTE data show that 36 patients (52.9%) had moderate right-to-left shunt (RLS), and 32 patients (47.1%) had massive RLS. cTTE was reexamined 6 months after operation and 1 case in the moderate RLS group had minimal RLS, 2 cases in the large RLS group had minimal RLS, and no shunts were seen for the rest. The VAS, HIT-6 and MIDAS scores before and 6 months after the operation were 7.65 ± 1.39 vs. 1.28 ± 1.53, 70.78 ± 6.82 vs. 41.53 ± 6.07, and 30.60 ± 13.24 vs. 1.93 ± 3.87, respectively. All the indexes 6 months after the operation significantly improved compared with the preoperative baseline (P < 0.05).

CONCLUSIONS

cTTE combined with migraine evaluation scale could be used as an objective index to evaluate the clinical effect of PFO occlusion.

A Challenging Interventional Procedure: Transcatheter Closure of Tubular Patent Ductus Arteriosus in Patients with Pulmonary Hypertension

Transcatheter closure of the tubular ducts remains the most challenging procedure, with higher complication rates than other types. This study evaluates the characteristics of transcatheter closure of tubular ducts with pulmonary hypertension. 73 patients with tubular ducts who underwent cardiac catheterization for transcatheter PDA closure were analyzed. The mean age and weight were 1.93 ± 2.68 years and 8.83 ± 6.14 kg, respectively. Transcatheter closure was attempted in 72 patients. Four cases (5.5%) were referred to surgery, while the procedure was completed in the remaining (94.5%). Amplatzer duct occluder (ADO) I or Cardiofix duct occluder (CDO) was the most commonly used devices. However, the use of Amplatzer vascular plug (AVP) II raised in recent years. The most common concern was aortic protrusion/stenosis in ADO I/CDO devices, but most regressed during follow-up. Iatrogenic coarctation of the aorta was observed in two with ADO I/CDO. Embolization of the device to the pulmonary artery was observed in three with CDO, AVP II, and AVP I. Significant left pulmonary artery stenosis requiring stenting developed in one after closure with an MVSDO device. Tubular ducts are highly associated with pulmonary arterial hypertension, and transcatheter closure of them is still challenging despite the developing device armamentarium. Although ADO I or similar devices are widely used, off-label devices are usually needed at increasing rates. The AVP II device is unsuitable for short tubular ducts but seems the best option for long ones.

Comparative Effectiveness of Surgical Ligation and Catheter Closure of Patent Ductus Arteriosus in Preterm Infants

To evaluate the association, if any, between closure modality (surgical ligation SL vs. catheter CC) of a hemodynamically significant patent ductus arteriosus (PDA), after failure of or contraindication to medical therapy, and immediate procedural complications, and post-procedure physiologic status in preterm (gestational age < 32 weeks) infants. In this single-center retrospective cohort study, data were accessed on infants < 32 weeks gestation, who underwent SL or CC of PDA, born from 2019-2021. The choice of modality was determined by parents, after they were provided information on both procedures. Our cohort (n = 112) included 36 (32.1%) infants who underwent SL while 76 (67.9%) underwent CC. The SL group of infants were significantly more immature at birth, younger on admission to the level IV NICU and received more mean (SD) surfactant doses than the CC group. Higher proportions of infants in the SL group had 5-min Apgar scores ≤ 5, seizures, severe intracranial hemorrhage and had received medical therapy for PDA. Both procedures were highly efficacious, with 1 unsuccessful device placement attempt and had low associated adverse events. Two (2.6%) infants had device migration 24 h after CC. SL was associated with a higher rate of immediate postoperative hypothermia whereas, in the CC group, mean airway pressure was significantly lower 48 h after, compared to before the procedure. SL and CC are comparable in short-term efficacy and safety for PDA closure. Long-term outcomes data are needed following both procedures.

Transcatheter closure of perimembranous ventricular septal defect using a novel fully bioabsorbable occluder: multicenter randomized controlled trial

Although the use of bioabsorbable occluder is expected to reduce the risk of metal occluder-related complications, it has not been approved due to incomplete degradation and new complications. Novel fully bioabsorbable occluders were designed to overcome such limitations. The aim of this study was to investigate the efficacy and safety of a fully biodegradable occluder in patients with ventricular septal defects. 125 patients with perimembranous ventricular septal defect (VSD) larger than 3 mm were screened from April 2019 to January 2020 in seven centers. 108 patients were enrolled and randomized into the bioabsorbable occluder group (n = 54 patients) and nitinol occluder group (n = 54). A non-inferiority design was utilized and all patients underwent transcatheter device occlusion. Outcomes were analyzed with a 24-month follow-up. All patients were successfully implanted and completed the trial. No residual shunt >2 mm was observed during follow-up. Transthoracic echocardiography showed a hyperechoic area corresponding to the bioabsorbable occluder which decreased primarily during the first year after implantation and disappeared within 24 months. Postprocedural arrhythmia was the only occluder-related complication with an incidence of 5.56% and 14.81% for the bioabsorbable and nitinol groups, respectively (P = 0.112). The incidence of sustained conduction block was lower in the bioabsorbable occluder group (0/54 vs. 6/54, P = 0.036) at 24-month follow-up. In conclusion, the novel fully bioabsorbable occluder can be successfully and safely implanted under echocardiography guidance and reduce the incidence of sustained postprocedural arrythmia. The efficacy and safety of this fully biodegradable occluder are non-inferior to that of a traditional nitinol one.

Hemodynamic and Echocardiographic Characteristics and the Presence of Pulmonary Hypertension in Patent Ductus Arteriosus Patients who Underwent Transcatheter Closure

We investigated the hemodynamic parameters of pediatric PDA patients and focused on the influence of PDA size on pulmonary arterial pressure and the prevalence of pulmonary hypertension. A total of 52 patients aged between 2 months and 20 years who received transcatheter closure of a PDA from January 2018 to June 2022 in our institution were retrospectively recruited. Their hemodynamic parameters collected both by echocardiography and by cardiac catheterization were analyzed to delineate the influence of PDA size on the pulmonary vascular system. The echocardiographic-based ductal size and indexed PDA size were 1.93 mm (1.15-6 mm) and 4.05 mm/m² (2.03-25.47 mm/m²), respectively. The pulmonary artery pressure measured was 20.83 mmHg (8-45 mmHg). We found a positive correlation between indexed PDA size and mean pulmonary arterial pressure (mPAP) (Pearson correlation coefficient = 0.47, p < 0.001). A subgroup analysis showed that 28 patients (53.8%) developed pulmonary hypertension (PH) (defined as mPAP > 20 mmHg). The median age of the PH group was 1.02 years [range: 0.19-8.64], which was significantly younger than the non-PH group's median age of 3.43 years [range: 0.42-19.96] (p = 0.001). The indexed PDA size for the PH group, 4.69 mm/m², was significantly higher than that of the non-PH group, 3.2 mm/m² (p = 0.004). The major risk factor for patients with PH was the PDA/BSA index, with an OR of 2.181 (95% CI, 1.224-3.887). Our demographic data showed younger patients with a higher PDA/BSA index are more likely to develop pulmonary hypertension.

Aortic Regurgitation Requiring Unplanned Surgery following Transcatheter Closure of Ventricular Septal Defect in Children: Incidence and Risk Factors

INTRODUCTION

Our aim was to investigate the incidence and risk factors for aortic regurgitation (AR) requiring unplanned surgery after transcatheter closure of ventricular septal defect (VSD) in children.

METHODS

Medical records of 876 children with VSD who underwent transcatheter closure from July 2009 to September 2018 in our hospital were retrospectively reviewed. Groups with and without new-onset or increasing AR requiring unplanned surgery were compared. Univariate and multivariate analyses were used to identify the possible risk factors. Smoothing plot and threshold effect analysis were carried out to find the relationship between possible factors and risk of new-onset or increasing AR.

RESULTS

A total of 29 children (3.3%) underwent unplanned surgery after transcatheter closure owing to new-onset or increasing AR, including 6 children with new-onset AR and 23 children with increasing AR. Multivariate regression analysis revealed that preoperative mild AR (OR: 60.39, 95% CI: 11.53-316.30, p < 0.001), larger ratio between diameter to body surface area (OR: 1.25, 95% CI: 1.01-1.55, p = 0.039), intracristal VSD (OR: 34.09, 95% CI: 4.07-285.65, p < 0.001), and shorter distance from the upper edge of defect to the aortic valve (or the sub-aortic rim) (OR: 0.12, 95% CI: 0.05-0.27, p < 0.001) were risk factors for new-onset or increasing AR requiring unplanned surgery. And, low risk of AR after muscular VSD transcatheter closure was found. An L-shaped nonlinear relationship between the sub-aortic rim and the risk of new-onset or increasing AR was observed, and the risk of new-onset or increasing AR with the sub-aortic rim up to the turning point (2 mm) (adjusted OR: 0.00, 95% CI: 0.00-0.08; p =0.001). With a median time of 7.3 years' follow-up, no new-onset or increasing AR has been found for children who initially did not have unplanned surgery.

CONCLUSION

Preoperative mild AR, larger ratio between diameter to body surface area, intracristal VSD, and shorter distance of the sub-aortic rim (especially <2 mm) could increase the risk of new-onset or increasing AR requiring unplanned surgery after transcatheter closure of VSD.

The first case of transcatheter device closure of perimembranous ventricular septal defect in Nigeria: a case report

Ventricular septal defect (VSD) is the most common congenital cardiac anomaly with a prevalence of 1.17 per 1000 live births. Haemodynamically significant VSDs require closure either surgical or transcatheter. We report a case of transcatheter device closure of a moderate-sized perimembranous ventricular septal defect (PmVSD), the first of its kind in Nigeria. The procedure was performed on a 23-month-old female weighing 10 kg who had presented with a history of frequent pneumonia and poor weight gain and signs of heart failure. The procedure was uncomplicated, and she was discharged 24 hours after the intervention. She had been followed-up two years post-procedure without complications and she had achieved appreciable weight gain. This non-surgical option was effective in this patient and provided the advantage of limited hospitalization, accelerated recovery, and intervention without the need for blood products. Such interventions should be scaled up in Nigeria and other sub-Saharan African countries.

Three-dimensional Transesophageal Echocardiography for Transcatheter Patent Foramen Ovale Closure: Standardizing Anatomic Nomenclature and Novel Sizing Concepts

•

Terminology for PFO tunnel sizing remains unstandardized.

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Device size selection for transcatheter PFO closure is highly variable.

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Tunnel width measurements may be a better descriptor of PFO size.

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Wire sizing may be a useful technique for assessment of PFO dimensions.

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PFO sizing strategies based on tunnel width need to be better studied.

Phase contrast cardiac magnetic resonance imaging versus transoesophageal echocardiography for the evaluation of feasibility for transcatheter closure of atrial septal defects

Background

This prospective study was aimed at comparing phase contrast cardiac magnetic resonance imaging (PC-CMR) with 2D transoesophageal echocardiography (TEE) for determining potential candidature for transcatheter closure in ostium secundum ASD (OS-ASD) patients. We included consecutive adult patients with OS-ASD for the evaluation of feasibility for transcatheter closure using 2D-TEE and PC-CMR over a period of 2 years. Patients who fulfilled the conventional criteria for transcatheter closure, i.e. maximum ASD diameter ≤ 34 mm, adequate rims (≥ 5 mm, except for anterosuperior rim), and normal pulmonary venous drainage on both imaging modalities, were taken for device closure. In patients where there was discrepancy in the measurements of ASD diameter or rim size, making them eligible for device closure on one imaging modality and ineligible on the other hand, provisional device closure was attempted. All patients who underwent transcatheter closure were followed up to 6 months to rule out any complications.

Results

A total of 58 patients (mean age 35.93 ± 10.59 years) were enrolled in the study. Overall, there was significant positive correlation between 2D-TEE and CMR measurements of maximal ASD diameter and rim size (p < 0.001). However, TEE significantly underestimated maximal ASD diameter and posteroinferior rim size in comparison with CMR (p = 0.013 and p = 0.023, respectively). 46 (79.3%) patients were suitable for transcatheter closure on CMR, while 44 (75.9%) were eligible on TEE. Transcatheter closure was attempted in 48 patients based on imaging findings and was successful in 46 (95.8%) patients. Device closure was unsuccessful in 2 patients with defect size < 34 mm on TEE but > 34 mm on CMR. Among 7 patients with deficient posteroinferior rim on TEE, 5 had sufficient rim on CMR and underwent successful transcatheter closure. CMR detected anomalous pulmonary venous drainage in one patient which was missed on TEE, hence excluding the patient from transcatheter closure. Mean device size was 28.3 ± 7.4 mm and correlated more strongly with the defect dimensions on PC-CMR (r = 0.85, p < 0.001) compared to TEE (r = 0.71, p = 0.02).

Conclusions

PC-CMR may to be superior to 2D-TEE for the preprocedural planning and feasibility assessment for transcatheter closure in adult patients with ostium secundum ASD.

Iatrogenic Atrial Septal Defect Requiring Transcatheter Closure Following Transcatheter Mitral Valve Repair

BACKGROUND

Transcatheter mitral valve repair with the MitraClip system has been established in selected high-risk patients. The MitraClip procedure results in a relatively large iatrogenic atrial septal defect (iASD). This study aimed to investigate the prevalence and clinical course of iASD requiring transcatheter closure following the MitraClip procedure.Methods and Results: This study was conducted at all 59 institutions that perform transcatheter mitral valve repair with the MitraClip system in Japan. The data of patients on whom transcatheter iASD closure was performed were collected. Of the 2,722 patients who underwent the MitraClip procedure, 30 (1%) required transcatheter iASD closure. The maximum iASD size was 9±4 mm (range, 3-18 mm). The common clinical course of transcatheter iASD closure was hypoxemia with right-to-left shunt or right-sided heart failure with left-to-right shunt. Of the 30 patients, 22 (73%) required transcatheter closure within 24 h following the MitraClip procedure, including 12 with hypoxemia and 5 with right-sided heart failure complicated with cardiogenic shock. Of the 5 patients, 2 required mechanical circulatory support devices. Twenty-one patients immediately underwent transcatheter iASD closure, and hemodynamic deteriorations were resolved; however, 1 patient died without having undergone transcatheter closure.

CONCLUSIONS

Transcatheter iASD closure was required in 1% of patients who underwent the MitraClip procedure. Many of these patients immediately underwent transcatheter iASD closure because of hypoxemia with right-to-left shunt or right-sided heart failure with left-to-right shunt.

Transcatheter closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim under echocardiography only: a feasibility and safety analysis

BACKGROUND

The safe closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim is a controversial issue. Few studies have been conducted on the closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim without fluoroscopy. This study evaluated the feasibility and safety of echocardiography-guided transcatheter closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim.

METHODS

The data of 136 patients who underwent transcatheter atrial septal defect closure without fluoroscopy from March 2017 to March 2020 were retrospectively analysed. The patients were classified into the deficient (n = 45) and sufficient (n = 91) posterior-inferior or inferior vena cava rim groups. Procedure and the follow-up results were compared between the two groups.

RESULTS

Atrial septal defect indexed diameter and the device indexed diameter in the deficient rim group were both larger than that in the sufficient rim group (22.12 versus 17.38 mm/m2, p < 0.001; 24.77 versus 21.21 mm/m2, p = 0.003, respectively). There was no significant difference in the success rate of occlusion between two groups (97.78% in the deficient rim group versus 98.90% in the sufficient rim group, p = 1.000). During follow-up, the incidence of severe adverse cardiac events was not statistically significant (p = 0.551).

CONCLUSIONS

Atrial septal defect with deficient posterior-inferior or inferior vena cava rim can safely undergo transcatheter closure under echocardiography alone if precisely evaluated with transesophageal or transthoracic echocardiography and the size of the occluder is appropriate. The mid-term results after closure are similar to that for an atrial septal defect with sufficient rim.

Safety and efficacy of percutaneous patent ductus arteriosus closure: a multicenter Egyptian experience

Background

Transcatheter closure of patent ductus arteriosus (PDA) has gained acceptance over the last two decades, replacing the surgery in more than 90% of the cases, so the safety and efficacy of transcather closure of PDA have been evaluated by studying different experiences from different centers in developing countries. The aim is to report our experience with PDA transcather closure, with focus on the adverse events and complications faced during the procedure.

Results

Outcome data on PDA transcatheter closure were collected from two different tertiary centers in a multicenter registry. During the period from June 2017 till January 2021, 308 PDA closure were recorded, using device in 197 (64%) and coils in 111 (36%) patients, most of the patients were in pediatric age group from 6 months to 6 years and only 10 patients (3.2%) were adults. Most patients had isolated PDA of 92%, and 9 (2.9%) patients had residual PDAs either post-surgical or transcatheter closure. Median minimum PDA diameter was 2.8 mm (range 1–7.6 mm; IQR 1.8–3.8 mm). The procedure was successful in 293 patients (95%). Complications occurred in 15/308 patients (5%), and only 6 (2%) of them were major complications, but none was life threating. Frequent complications were device embolization (2%), hemolysis (1%), arrhythmia (1%). Younger age, low body weight and longer procedure time were associated with a high complication rate (p < 0.005). Device-related complications were more common than coil-related complications (2.5% versus 0.5%).

Conclusions

Although transcatheter closure of PDA is considered to be effective procedure with low complications rate, however, complications should be anticipated and managed properly.

Transcatheter closure of ventricular septal defects in children less than 10 kg: experience from a tertiary care referral hospital in Eastern India

OBJECTIVE

To assess the feasibility of percutaneous transcatheter device closure of ventricular septal defects in children weighing less than 10 kg.

BACKGROUND

Although percutaneous transcatheter device closure of ventricular septal defect is a well-established method of treatment in older children and adolescents, there is limited data on device closure in small children weighing less than 10 kg. We present our institutional experience of transcatheter VSD closure in children weighing less than 10 kg.

METHOD

Medical records were reviewed for 16 children, who were selected for device closure of ventricular septal defects based on the inclusion criteria.

RESULTS

Out of 65 patients with a diagnosis of ventricular septal defect, 16 children less than 10 kg were attempted for percutaneous device closure. In 13 patients, the device was successfully released, and 3 patients needed surgical closure of the defect. Mean age and weight of the patients were 17.3 ± 12.7 months and 6.8 ± 3.2 kg, respectively. Mean defect size was 6 mm (range 3-10). There was no incidence of device embolisation or heart block or death. Five patients had residual left-to-right shunt immediately after the device release, which got closed by the first month's follow-up. We had one accidental perforation of right ventricular free wall at the time of crossing of the defect, which was successfully repaired surgically.

CONCLUSION

Percutaneous device closure of ventricular septal defect in small children with weight below 10 kg is feasible with good short-term outcome. Careful patient selection is essential for procedural success and to avoid complications.

Patent ductus arteriosus: From pharmacology to surgery

Patent ductus arteriosus (PDA) may be found in 0.1-0.2% of term infants, but the average incidence is at least five-fold higher in premature infants, correlating inversely with birth weight and gestational age. While not all patients with a PDA require treatment, the deleterious effects of persistent left-to-right shunting across the ductus can have important short- and long-term consequences. Medical and interventional approaches to PDA closure have evolved greatly in the past decade and add to the decision-making pathways. This article summarizes the pathophysiology of PDA and characterizes the medical, surgical and endovascular treatment approaches.

Transcatheter closure for decompression sickness with a patent foramen ovale: A case report

A patent foramen ovale is one of the predisposing factors of neurotic decompression sickness. Transcatheter closure of a patent foramen ovale is effective in the secondary prevention of decompression sickness associated with intracardiac shunt. The size of the umbrella should not be limited to the diagnosis of a patent foramen ovale or an atrial septal defect but should be determined by the supporting force of the soft margin of the atrial septum. The surgical method of patent foramen ovale closure is the same as that of the closure of an atrial septal defect, but the closure umbrella of a patent foramen ovale is different from that of the closure umbrella of an atrial septal defect. The size of the umbrella of the right atrium is larger than that of the left atrium, and it is better to close the atrial septum.

Transcatheter patent arterial duct closure in premature infants: A new technique to ease access to the patent arterial duct, with particular benefit for the tricuspid valve

BACKGROUND

Transcatheter patent arterial duct (PAD) closure in premature infants has been shown to be feasible. Since our early transcatheter PAD closure procedures in premature infants at Hôpital Necker Enfants Malades, we have changed our technique several times to advance the guidewire through the right heart to avoid tricuspid valve damage.

AIM

To describe the technique we have been using since May 2019, to report our results with a particular focus on tricuspid leaks and to analyse the potential mechanisms of tricuspid lesion development with previous methods.

METHODS

All premature infants weighing<2kg who underwent transcatheter PAD closure with this new technique were included. Demographic data, procedural data, outcome and procedural complications were reviewed, with particular attention to the occurrence of tricuspid regurgitation.

RESULTS

Between May 2019 and May 2020, 33 patients were included. Median gestational age was 25 weeks. Median birth weight and procedural weight were 690g (range 490-1065g; interquartile range [IQR] 620-785g) and 1160g (range 900-1900g; IQR 1030-1300g), respectively. Median age at procedure was 35 (IQR 30-46) days. PAD anatomy was evaluated on transthoracic echocardiography only. The median duct diameter was 3 (IQR 2.5-3.2) mm at the pulmonary end. Success rate was 100% (defined as successful closure without residual shunt). One patient had a renal vein thrombosis, which fully resolved with low-molecular-weight heparin anticoagulation. No tricuspid regurgitation or stenosis of the left pulmonary artery or the aorta was seen. One patient died of a superior caval vein obstruction with bilateral chylothorax related to a central catheter thrombosis 56 days after the procedure, unrelated to the catheter procedure.

CONCLUSION

In this prospective study, we describe a new technique to avoid tricuspid valve damage and facilitate delivery of the PAD device.

Transcatheter closure of paravalvular leaks: short and medium-term outcomes

Background

Paravalvular leak is a frequent and important complication after surgical valvular replacement that can cause heart failure, hemolytic anemia and is associated with poor clinical outcomes. Surgical reoperation has been the standard treatment, but it is associated with high morbidity and mortality. Transcatheter closure is a therapeutic alternative. The aim of the present study is to analyze the feasibility and the short and medium-term outcomes of the transcatheter closure of paravalvular leaks.

Methods

Single-centre registry of consecutive patients with post-surgical paravalvular leaks, that underwent transcatheter closure, between January 2006 and December 2016. Efficacy and safety results were analyzed during the procedure and at 6-month follow-up.

Results

21 paravalvular leaks (15 mitral, 5 aortic and 1 tricuspid) were closure during 20 procedures. In the initial echocardiography 91% of the leaks were severe. The most used device was the Amplatzer Vascular Plug III® in 10 procedures (50%). The 3D transesophageal echocardiography was used in 70% of cases. The device was successfully implanted in 95% of cases, a regurgitation reduction ≥ 1 grade was achieved in 95% of the cases, and the clinical success was 79%. Six month survival was 100%; however, 3 cases required valvular surgery (15%).

Conclusions

Transcatheter closure of paravalvular leaks is a feasible and safe procedure with high rates of technical, echocardiographic and clinical success in the short and medium term. It is an adequate therapeutic alternative, mainly in high surgical risk patients and multiples comorbidities.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure

BACKGROUND

Atrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure.

METHODS

This retrospective study included a total of 314 patients (mean age: 39.5 (30-50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development.

RESULT

Fifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52-9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05-7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01-1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia.

CONCLUSION

The presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Coronary artery changes in congenital coronary-cameral fistulas evaluated by computed tomographic angiography

PURPOSE

The study sought to determine coronary artery diameter in congenital coronary-cameral fistula (cCCF), factors associated with coronary artery aneurysm, coronary artery changes after fistula closure, and computed tomographic (CT) findings after treatment.

MATERIALS AND METHODS

We retrospectively reviewed CT findings of the cCCF for origins, terminations, fistula length, complexities, and Sakakibara classification. Coronary artery diameter was expressed as coronary artery Z score. Fistula features associated with coronary artery aneurysm were analyzed. Post-fistula closures were analyzed for coronary artery dilatation, coronary thrombosis, complete fistula closure, and fistula thrombosis.

RESULTS

Twenty-five patients (median age 33 months, interquartile range, IQR 25-48) were included. Coronary feeders and terminations were frequently right coronary artery (48%) and right ventricle (56%), respectively. Fistula aneurysm occurred in 52% of cases. Mean coronary artery Z score was 13.03 ± 6.36 with a high incidence of giant coronary artery aneurysm (68%). We found no statistically significant risk factors associated with coronary artery aneurysm (p value range 0.075-0.370). Median duration of the follow-up CT after closure of the fistulas was 6.4 months (IQR 5.0-8.7). Coronary artery Z score significantly decreased by 0.82 (IQR 0.28-1.35), p = 0.006 and coronary thrombosis occurred in 23% of cases during follow-up.

CONCLUSIONS

Large coronary aneurysm is common in cCCF. No characteristic feature of the fistula influencing coronary artery aneurysm is identified. There is a diminution in coronary artery Z score after fistula closure. Coronary thrombosis is a major complication after treatment.

Cost comparison of transcatheter and operative closures for patients with secundum atrial septal defects in Vietnam

We aim to estimate and compare the costs of operative and transcatheter closure for patients with secundum atrial septal defect (ASD) in Vietnam. This was a retrospective cross-sectional study based on medical records of congenital heart diseases (CHD) patients in Da Nang Hospital, Vietnam from 2010 through 2015. All costs in this study were calculated according to a provider's perspective. All pricing data were converted into USD at the 2015 exchange rate. A total of 258 patients with secundum ASD were recruited in the study, including 35 patients treated by operative closure and 223 patients treated by transcatheter closure. The total treatment costs of the transcatheter closure group (US $3,107.9) were higher than those of the operative closure group (US $2,080.5). The cost of the procedure and medical supplies accounted for 67.3% of the total treatment cost in the operative closure group, while the cost of occlusion devices accounted for 62.2% of the total cost in the transcatheter closure group. Given the advantages of the transcatheter closure procedure, reducing occlusion device costs may increase the proportion of patients treated with this technique.

Efficacy and safety of atrial septal defect closure using Occlutech Figulla Flex II compared with Amplatzer Septal Occluder

Few studies have reported the efficacy of Occlutech Figulla Flex II (FFII) device compared with Amplatzer Septal Occluder (ASO) device. The aim of this study was to examine the efficacy and safety of FFII compared with ASO for transcatheter atrial septal defect (ASD) closure. We retrospectively evaluated 190 patients using FFII and 190 patients using ASO who underwent transcatheter ASD closure. ASD characteristics were evaluated by transesophageal echocardiography. The prevalence of procedural complications, including erosion, device embolization, stroke, and new-onset atrial arrhythmia, and the presence of a residual shunt were evaluated between the two groups during 12-month follow-up. FFII was used more frequently than ASO in patients with a deficient aortic rim or septal malalignment (P = 0.02, P < 0.01, respectively). The procedural complications of erosion, device embolization, and stroke did not occur in any patients. New-onset atrial arrhythmia occurred in 3 patients of the FFII group and 4 patients of the ASO group, and the difference between the two groups was not significant (P = 0.70). A large residual shunt (≥ 3 mm) was observed in 6 patients of the FFII group and 5 patients of the ASO group, and the difference between the two groups was not significant (P = 0.76). FFII was used frequently in patients with high-risk ASD morphology; however, there was no difference in the prevalence of procedural complications or efficacy between patients using FFII and those using ASO.

Fate of the Left Pulmonary Artery and Thoracic Aorta After Transcatheter Patent Ductus Arteriosus Closure in Low Birth Weight Premature Infants

Transcatheter patent ductus arteriosus closure (TCPC) is an emerging treatment for low birth weight extremely premature neonates (EPNs). Left pulmonary artery (LPA) and descending aorta (DAO) obstruction are described device-related complications, however, data on mid- and long-term vascular outcomes are lacking. A retrospective analysis of EPNs who underwent successful TCPC at our institution from 03/2013 to 12/2018 was performed. Two-dimensional echocardiography and spectral Doppler velocities from various time points before and after TCPC were used to identify LPA and DAO flow disturbances. A total of 44 EPNs underwent successful TCPC at a median (range) procedural weight of 1150 g (755-2500 g). Thirty-two (73%) patients were closed with the AVP II and 12 (27%) with the Amplatzer Piccolo device. LPA and DAO velocities on average remained within normal limits and improved spontaneously in long-term follow up (26.1 months, range 1-75 months). One patient, who had concerning LPA flow characteristics immediately after device implant (peak velocity 2.6 m/s) developed progressive LPA stenosis requiring stent placement 3 months post-procedure. In the remaining infants, including 7 (16%) who developed LPA and 3 (7%) who developed DAO flow disturbances (range 2-2.4 m/s), all had progressive normalization of flow velocities over time. TCPC can be performed safely in EPNs with a low incidence of LPA and DAO obstruction. In the absence of significant progressive vascular obstruction in the early post-procedure period, mild increases in LPA and DAO flow velocities tend to improve spontaneously and normalize in long-term follow-up.

Transcatheter closure for patent ductus arteriosus in patients with Eisenmenger syndrome: to do or not?

BACKGROUND

Patent ductus arteriosus (PDA) complicated by Eisenmenger syndrome (ES) remains to be a major cause of morbidity and mortality worldwide. Giving increasing evidences of benefit from targeted therapies, ES patients once thought to be inoperable may have increasing options for management. This study aims to explore whether PDA in patients with ES can be treated with transcatheter closure (TCC).

METHODS

Between August 2014 and July 2016, four of fifteen PDA-ES patients whose Qp/Qs improved significantly and Qp/Qs > 1.5 after acute vasodilator testing with 100% oxygen were selected to receive TCC and pulmonary vasodilator therapy. PAH-targeted drugs were prescribed before and after occlusion for all. Trial occlusion was performed before permanent closure.

RESULTS

The first TCC failed after initiation of PAH-targeted drugs for 6 months in four patients. After the medication was adjusted and extended to 12 months, TCC was performed for all without hemodynamic intolerances during perioperative period. Pulmonary artery systolic pressure (PASP) was significantly decreased (≥ 40%) immediately after TCC. During a mean follow-up of 48 ± 14.70 months, there were a further decrease of PASPs in two patients, the other two showed improved pulmonary vascular resistance, WHO functional class and six-minute walking distance despite deteriorated PASP.

CONCLUSION

Some selected PDA-ES patients might benefit from TCC and combined PAH-targeted drugs play a crucial role.

Appropriate device selection for transcatheter atrial septal defect closure using three-dimensional transesophageal echocardiography

Detail morphological evaluation for ASD is essential to achieve successful transcatheter closure. Three-dimensional transesophageal echocardiography (3D-TEE) is emerging, but few studies have comprehensively verified the usefulness of 3D-TEE. We divided 329 patients who underwent transcatheter ASD closure at our university hospital into 157 in the Conventional group evaluated with 2-dimensional transesophageal echocardiography and balloon sizing (BS), and 172 in the 3D-TEE group evaluated with 3D-TEE additionally. We assessed usefulness of 3D-TEE and consider appropriate device selection procedure. Overall, the percentage with re-sizing of device tended to be lower in the 3D-TEE group than in the Conventional group (10.1% vs 6.0%, p = 0.187). Among preprocedural modalities, the device size was mainly decided based on the BS diameter. A logistic regression analysis demonstrated that large atrial septum aneurysms (ASA) were associated with a ≥ 2 mm discrepancy of the BS diameter from the preprocedural 3D-TEE diameter (p < 0.05). Compared to the Amplatzer Septal Occluder, the differences in device size and the preprocedural ASD measurement were greater when using the Occlutech Figulla Flex II Occluder (FFII). Particularly, among the patients implanted with FFIIs, the discrepancies of the device size from the 3D-TEE measurement were greater in patients with large ASA than those with small ASA. Preprocedural 3D-TEE is useful to select the appropriate device size. Particularly, it is necessary to select a much larger device than that derived from the preprocedural 3D-TEE measurement when using FFII in patients with a septal aneurysm.

Hybrid retrieval of embolized device in abdominal aorta after transcatheter closure of large patent ductus arteriosus

Patients with a large patent ductus arteriosus (PDA) can have several presentations. Many will be asymptomatic, some could develop severe pulmonary hypertension, and others can develop Eisenmenger syndrome. We have presented a case in which a PDA correction device was embolized to the abdominal aorta, 2 months after transcatheter closure of a large PDA. The patient presented with an acute abdomen. In the management of the case, we implemented a hybrid technique in the process of device retrieval. Transbrachial access and a lower abdominal midline incision were accomplished to dislodge the device from the supraceliac aorta to the aortic bifurcation. The Amplatzer Ductal Occluder (St Jude Medical Inc, St Paul, Minn) was extracted through a small arteriotomy of the distal abdominal aorta. The procedure was followed by a dramatic improvement of the ischemic liver and bowel, evidenced by the vanishing of the cyanotic hue of the liver and normalization of the bluish discoloration of the intestine.

Early changes in ambulatory electrocardiography after transcatheter closure in patients with atrial septal defect and factors affecting heart rate variability

Background

Factors affecting heart rate variability (HRV) in patients with atrial septal defect (ASD) have not been clarified. This study sought to identify those factors and establish a preliminary risk model.

Methods

A total of 154 patients with ASD who underwent transcatheter closure and met the study requirements were analyzed in this study. Moreover, 26 patients with patent foramen ovale (PFO) were enrolled in our study as a control group. All patients underwent echocardiography and ambulatory electrocardiography before and one day after the procedure.

Results

The standard deviation of all normal-to-normal (NN) intervals (SDNN) and the standard deviation of the averages of the NN intervals in all 5 min segments of the entire recording (SDANN) were significantly higher and the heart rate was lower after closure than before closure in patients with ASD (SDNN: 6.08, 95% CI 3.00 to 9.15, p < 0.001; SDANN: 7.57, 95% CI 4.50 to 10.64, p < 0.001; heart rate: -1.17, 95% CI − 2.86 to − 0.48, p = 0.006). Multiple regression analyses indicated that age, sex, defect diameter, heart rate and diabetes were significantly associated with HRV indices (SDNN: R² = 0.415; P < 0.001). SDNN and SDANN had obvious correlations with right ventricular systolic pressure (SDNN: R = − 0.370, p < 0.001; SDANN: R = − 0.360, p < 0.001).

Conclusions

Factors affecting HRV in patients with ASD include age, sex, heart rate, defect size and diabetes. Furthermore, right ventricular systolic pressure plays an important role in the change in HRV.

Transcatheter closure of paravalvular leaks: short- and medium-term outcomes

Background

Paravalvular leak (PVL) is a frequent and important complication after surgical valvular replacement that can cause heart failure and hemolytic anemia and is associated with poor clinical outcomes. Surgical reoperation has been the standard treatment, but it is associated with high morbidity and mortality. Transcatheter closure is a therapeutic alternative. The aim of the present study is to analyze the feasibility and the short- and medium-term outcomes of the transcatheter closure of PVLs.

Methods

Single-center registry of consecutive patients with post-surgical PVLs that underwent transcatheter closure, between January 2006 and December 2016. Efficacy and safety results were analyzed during the procedure and at 6-month follow-up.

Results

Twenty-one PVLs (15 mitral, 5 aortic, and 1 tricuspid) were closure during 20 procedures. In the initial echocardiography, 91% of the leaks were severe. The most used device was the Amplatzer Vascular Plug III^® in 10 procedures (50%). The three-dimensional transesophageal echocardiography was used in 70% of cases. The device was successfully implanted in 95% of cases, a regurgitation reduction ≥ 1 grade was achieved in 95% of the cases, and the clinical success was 79%. Six-month survival was 100%; however, three cases required valvular surgery (15%).

Conclusions

Transcatheter closure of PVLs is a feasible and safe procedure with high rates of technical, echocardiographic, and clinical success in the short and medium term. It is an adequate therapeutic alternative, mainly in high surgical risk patients and multiples comorbidities.

Spanish registry of percutaneous VSD closure with NitOcclud Lê VSD Coil device: lessons learned after more than a hundred implants

INTRODUCTION AND OBJECTIVES

The NitOcclud Lê VSD Coil was specifically designed for transcatheter occlusion of ventricular septal defects (VSD) and became available for this purpose in August 2010. Our objective was to describe the Spanish experience of this technique and analyze its reliability and short- to mid-term efficacy.

METHODS

National multicenter observational study, which retrospectively recruited all patients (of any age) with VSD (of any location or type) who underwent percutaneous NitOcclud occlusion, using an intention-to-treat analysis, until January 2019.

RESULTS

A total of 117 attempts were made to implant at least 1 NitOcclud in 116 patients in 13 institutions. The median [range] age and weight was 8.6 [0.4-69] years and 27 [5.8-97] kg, respectively. In 99 patients (85%), the VSD was an isolated congenital defect. The location was perimembranous in 95 (81%), and 74 (63%) of them were aneurysmatic. The mean fluoroscopy time was 34 [11.4-124] minutes. Of the 117 attempts, 104 were successful (89%) with a follow-up of 31.4 [0.6-59] months. At the last review, final complete occlusion of the defect without residual shunt or with only a minimal shunt was achieved in 92.3% (no shunt, n=73; trivial shunt, n=23). Four patients required a second procedure for residual shunt occlusion. Two devices had to be surgically explanted due to severe hemolysis. There were no deaths or other major complications.

CONCLUSIONS

The NitOcclud device can be used successfully for a wide anatomical spectrum of VSD. The main issue is residual shunt, but its incidence decreases over time. The incidence of hemolysis was very low and no permanent changes were detected in atrioventricular conduction.

Transcatheter Closure of Atrial Septal Defects with Cardiac Computed Tomography Sizing: Eight-Year Single-Center Practice

INTRODUCTION

An accurate evaluation of atrial septal defect (ASD) is important for the success of interventional treatment. Cardiac computed tomography (CT) has unique advantages for ASD assessment, although transesophageal echocardiography (TEE) remains the accepted method.

OBJECTIVE

This study aimed to evaluate the safety and feasibility of transcatheter closure of ASD with cardiac CT sizing but without TEE measurement.

METHODS

Among 134 patients undergoing transcatheter closure, 13 underwent TEE in addition to a cardiac CT examination, and 121 underwent only cardiac CT. Propensity score matching was used to analyze the outcomes of the groups treated with (group 1) or without (group 2) TEE examinations. The success rate and complications among the 121 ASD patients with only cardiac CT sizing were recorded and analyzed. The maximal diameters of the defects remeasured on CT images were compared to the echocardiography results and correlated with the device size by Student t test and Pearson's linear regression analysis, respectively.

RESULTS

No significant differences (p > 0.05) were found between groups 1 and 2 in the success rate, complications, or ratio of the device size to the maximum diameter of the defect measured by cardiac CT. In group 1, the maximum diameters of the ASD derived from cardiac CT and TEE were comparable (22.08 ± 9.68 vs. 21.50 ± 10.24; p = 0.351). The success rate among the 121 patients who underwent transcatheter closure with only cardiac CT sizing was 99.2%; however, within 1 month of follow-up, 2 patients had arrhythmia, 1 patient had residual shunting, 1 patient had an infection, and 1 patient had a hematoma, but all patients recovered within a short time.

CONCLUSIONS

Cardiac CT seems to be comparable to TEE in the assessment of ASD, and transcatheter closure of ASD based on CT sizing alone is safe and feasible.

Preoperative Threshold for Normalizing Right Ventricular Volume After Transcatheter Closure of Adult Atrial Septal Defect

BACKGROUND

The latest guidelines recommend early intervention in adult atrial septal defect (ASD) patients with signs of right ventricular (RV) enlargement. However, the criteria of RV enlargement for optimal intervention remain unclear. We investigated the preoperative determinants for normalizing the RV volume after transcatheter closure of ASD in adults.Methods and Results:We retrospectively analyzed 52 ASD patients who underwent transcatheter closure. Cardiac magnetic resonance imaging (CMR) measured RV volume before and 1 year after the closure. The patients were divided into normalized (postoperative RV end-systolic volume index [RVESVI] <47 mL/m²and end-diastolic volume index [RVEDVI] <108 mL/m²) and non-normalized (postoperative RVESVI ≥47 mL/m²or RVEDVI ≥108 mL/m²) groups. Preoperative RVESVI was significantly smaller (72 mL/m²vs. 80 mL/m²) and RVEF was higher (56% vs. 51%) in the normalized group compared with the non-normalized group. Receiver-operating characteristic analysis for the normalization of postoperative RV volume showed that the preoperative threshold value of RVESVI was 75 mL/m². In addition, multivariate analysis showed that preoperative RVESVI was an independent predictor for normalization of RV volume.

CONCLUSIONS

Preoperative RVESVI is an independent predictor for normalization of RV volume at 1 year after transcatheter closure of ASD in adults. Early intervention before RVESVI reaches 75 mL/m²may confer optimal timing for normalizing RV volume.

Comparison of transcatheter patent ductus arteriosus closure between children and adults

The data comparing the characteristics and effect of transcatheter patent ductus arteriosus (PDA) closure between children and adults is scarce. We analyzed 54 consecutive patients who underwent transcatheter PDA closures. We divided the patients into 2 groups of < 18 years and ≥ 18 years and compared the hemodynamic changes before and after the PDA closure. Adults had a higher incidence of heart failure on admission, diagnoses by heart failure and incidental echocardiography, PDA calcifications, and procedural complications than children (all P < 0.05). The left ventricular end-diastolic volume index (LVEDVI), left atrial diameter index (LADI), and LV mass index (LVMI) decreased after the PDA closure in children but not in adults. The LV ejection fraction (LVEF) significantly decreased 1 day after the PDA closure in both groups but remained low at 6 months after the procedure in only adults. The percent change in the LVEDVI, LADI, LVMI, and LVEF from baseline to 6 months after the procedure was significantly lesser in adults than children (LVEDVI: - 5.2 ± 29.1% vs. - 34.9 ± 18.9%, LADI: - 7.0 ± 13.2% vs. - 22.1 ± 18.9%, LVMI: - 11.0 ± 16.5% vs. - 34.1 ± 15.7%, LVEF: - 5.9 ± 7.6% vs. 6.1 ± 9.1%, all P < 0.05). Transcatheter PDA closure was not associated with a reduction in the LV and LA volume as well as an improvement in the LV hypertrophy and LV function in adults as compared to children. We suggested that an early diagnosis and transcatheter PDA closure during childhood might provide clinical benefit before progressive LV remodeling and heart failure.

Elaborate evaluation of serial changes in electrocardiograms of atrial septal defects after transcatheter closure for a better understanding of the recovery process

Serial changes of electrocardiograms (ECG) could be used to assess their clinical features in atrial septal defects (ASD) after transcatheter closure together with other clinical parameters. We retrospectively studied 100 ASD patients who underwent transcatheter closure. Complications of persistent atrial fibrillation occurred in five ASD patients, and they were excluded. We divided the other 95 patients according to PQ intervals before closure (normal: < 200 ms, n = 51; prolonged: ≥ 200 ms, n = 44) to evaluate their clinical characteristics and parameters such as echocardiography, chest X-rays, and brain natriuretic protein (BNP) levels. Individuals in the prolonged PQ group were significantly older, had higher incidences of paroxysmal atrial fibrillation (PAF) and heart failure (HF) treated with more β-blockers and diuretics, and with a higher tendency of NYHA functional classification and BNP levels than the normal PQ group. The prolonged PQ group also had a significantly higher incidence of complete right bundle branch block, wider QRS intervals, and larger cardiothoracic ratios in chest X-rays accompanied by larger right atrial-areas and larger left atrial dimensions in echocardiograms. Furthermore, the prolonged PQ intervals with less PQ interval shortening after transcatheter closure revealed that the patients were the oldest at the time of closures and showed less structural normalization of the right heart and left atrium after ASD closure. PAF and HF also occurred more frequently in this subgroup. These results suggested that the ASD patients with prolonged PQ intervals with less PQ shortening were accompanied by more advanced clinical conditions. Together with other clinical parameters, detailed analyses of ECG and their changes after closure could elucidate the clinical characteristics and status of ASD patients with transcatheter closure and were useful for predicting structural normalization after transcatheter closure.

Effect of transcatheter closure by AmplatzerTM Duct Occluder II in patients with small ventricular septal defect

Transcatheter closure of ventricular septal defect (VSD) is an alternative treatment of surgery. However, because of the potential risk of the complete atrioventricular block (AVB) and the lack of available dedicated devices for VSD, this procedure rarely used most centers. Recently in Thailand, with distinct device design that may cause less clamp force and radial force, the Amplatzer^TMDuct Occluder (ADO) II has become available for the closure of small VSDs. This is a retrospective review of 49 patients who underwent transcatheter VSD closure using ADO II at Songklanagarind hospital and Queen Sirikit National Institute of Child Health between January 2014 and December 2016 with an intention to report procedural success rate and 12-months-outcomes. Twenty-six cases were female. The median age and weight at treatment were 7.8 year (ranged from 1.9 to 25 year) and 25.1 kg (ranged from 11 and 57 kg). The majority (65.3%) of the VSD was a perimembranous defect. The mean diameter of LV entry was 5.2 ± 2.5 mm and the mean RV exit was 3.2 ± 0.8 mm. Four patients had more than 1 exit at RV orifice. The mean length of the VSD was 5.3 ± 1.8 mm. The mean aortic valve-VSD distance was 3.9 ± 2.0 mm. The mean tricuspid valve-VSD distance was 3.8 ± 2.5 mm. The procedural success achieved in all patients (100%), most of the implantations were performed in a retrograde approach (53.1%). The ADO II was successfully implanted in 2 cases (5%) who failed other devices in the first attempts. There were no major complications. There were no changes in the severity of tricuspid and aortic valve regurgitation immediate after implantation and at 12 months' follow-up. Three patients (6%) had tiny to small residual shunt at 12 months' follow-up. None of the patients had a complete heart block. However, new-onset of left bundle branch block and right bundle branch block occurred in 2 (5%) cases and 5 (10%) cases, respectively. With symmetrical double-disc design and softness of the device, the ADO II can be safely and effectively used for closure of the VSDs with the defect size less than 6 mm.

Novel Strategy for Predicting Conduction Abnormalities During Transcatheter Closure of Perimembranous Ventricular Septal Defect in Adults

BACKGROUND

In this study we evaluated the feasibility and efficacy of predicting conduction system abnormalities under 3-dimensional (3D) electroanatomic mapping guidance during transcatheter closure of perimembranous ventricular septal defects (pmVSDs) in adults.Methods and Results:The distribution of the His-Purkinje system (HPS) close to the margins of pmVSDs in the left ventricle was identified using 3D electroanatomic mapping and near-field HPS was further confirmed by different pacing protocols. Of the 20 patients in the study, 17 (85%) were successfully treated by transcatheter intervention. The minimum distance between the margins of the pmVSD and near-field HPS, as measured by 3D electroanatomic mapping, ranged from 1.3 to 3.9 mm (mean [± SD] 2.5±0.7 mm). Five patients with a minimum distance <2 mm had a higher risk (3/5; 60%) for adverse arrhythmic events, whereas patients with a distance >2 mm were at a much lower risk (1/15; 6.7%) of procedure-related conduction block (P=0.032). No other adverse events were recorded during the follow-up period (median 30 months).

CONCLUSIONS

A minimum distance between the pmVSD and near-field HPS <2 mm was associated with a relatively high risk of closure-related conduction block. 3D electroanatomic mapping may be helpful in guiding decision making for transcatheter closure and reduce the incidence of adverse arrhythmic events.